Prostate cancer

• Older age.Prostate cancer is rare in men younger than 40, but the chance of having prostate cancer rises rapidly after age 50. About 60% of prostate cancers are diagnosed in men older than 65.
• Race/ethnicity.Prostate cancer develops more often in men of African and Caribbean descent  and when it does develop it is usually more aggressive and happens at a younger age.It is less common among Asian, Hispanic, and Latino men whereas Caucasians are somewhere in between.
• Family history. Prostate cancer is more common among some families, and in 3-7% of all cases there may be an inherited or genetic factor.Having a father or brother with prostate cancer more than doubles a man’s risk of developing this disease.The more affected relatives someone has,the higher the risk.
• Inherited gene changes.Certain gene changes that are inherited from a parent can raise prostate cancer risk, although these probably account for only a small percentage of prostate cancers overall.

There’s no proven prostate cancer prevention strategy. But you may reduce your risk of prostate cancer by making healthy choices, such as:

• choose a healthy diet
• maintain a healthy weight
• exercise most days of the week

It is recommended to have a baseline PSA at 45 years of age and based on those results , your Urologist will advise you on the proper scheme of monitoring.Men with high risk features should consult a Urologist at a younger age.

There is no specific normal or abnormal level of PSA in the blood. In the past, PSA levels of 4.0 ng/mL and lower were considered normal. However, some individuals with PSA levels below 4.0 ng/mL have prostate cancer and many with higher PSA levels between 4 and 10 ng/mL do not have prostate cancer.Other factors ,like age, prostate size and previous medical history need to be considered before proceeding with further tests.

Symptoms of prostate cancer do not usually appear until the prostate is large enough to affect the tube that carries urine from the bladder out of the penis called urethra or the disease itself is in an advanced stage.

When this happens, you may notice things like:

• an increased need to pee
• straining while you pee
• a feeling that your bladder has not fully emptied
• blood in urine
• in metastatic disease the patient can experience fatigue,weight loss and backache 

These symptoms should not be ignored, but they do not always mean you have prostate cancer.

Biopsy. If your doctor finds an abnormality during digital rectal examination or MRI, or if PSA testing detects a raised PSA level, you may need a biopsy.

Definitely yes. It has been proven that MRI can detect abnormalities of the prostate and along with other findings like PSA and prostate volume can guide the decision whether someone actually needs a biopsy.Actually in the most contemporary diagnostic pathways for prostate cancer MRI is the most valuable element.

The fusion biopsy technology combines your MRI images with the ultrasound image in real time. This fusion of images creates a clearer picture of any suspicious areas in the prostate and increases the precision of sample taking.

This is a matter of controversy. It is well known that in the hands of experts in prostate biopsy there is no significant difference in the detection rate of prostate cancer. Though because this technology is readily available in most hospitals it is advised to use it and benefit from its potential advantages.

The answer is simple, transperineal biopsy is safer as it carries a much lower risk of infection and most importantly, it is more accurate as with this approach we can sample areas of the prostate that it is impossible to reach with the traditional transrectal biopsy.

Your Urologist depending on your previous medical history,clinical examination, biopsy details ,PSA value and MRI findings will guide you to the specific tests you need to have.In those cases a one size fits all approach is not acceptable as each case has its own individual characteristics.

If you’ve just been diagnosed with prostate cancer, you might feel scared, worried, stressed or even angry. Your feelings may change over time. There’s no right way to feel and everyone reacts in their own way.

When you’re told you have cancer, it can be a shock and you might find it difficult to take everything in and cope with the information. Thinking about your cancer and possible treatments can be stressful and you may have lots of questions.

You may feel anxious about the future and how having prostate cancer will affect your life and your loved ones.

There are people who are there to support you and there are things you can do to help yourself. 

We advise patients to:

• Talk to someone.Share what you’re thinking,find someone you can talk to whether it’s your family, relatives or your doctor
• Set yourself goals and things to look forward to.
• Take time out to look after yourself. When you feel up to it, learn some techniques to manage stress and to relax – like breathing exercises or listening to music.
• Eat a healthy, balanced diet.
• Be as active as you can.Keeping active can improve your physical strength and fitness, and can lift your mood.Physical activity can also help with some side effects of treatment.

A prostate biopsy can be done under local anaesthesia or sedation depending on the patient’s preference after his Urologist fully explains what this procedure entails.

If you’ve had a treatment that aimed to get rid of your prostate cancer, such as surgery, radiotherapy or brachytherapy, you will have regular check-ups afterwards. This is often called follow-up.

The aim of this is to:

• check how your cancer has responded to treatment
• help you deal with any side effects of treatment
• give you a chance to raise any concerns or ask any questions.

Your doctor will set a detailed plan for you based on the treatment you had, it’s outcome and the characteristics of your disease.

In most cases, prostate cancer is relatively slow-growing and it can take years to become large enough to be detectable, and even longer to metastasize outside the prostate.

Prostate cancer, unfortunately, is common. It affects one in seven men, making it the second most common cancer among men. The good news is that prostate cancer can be curable, especially when identified and treated early.

Around 95 out of every 100 men (around 95%) will survive their cancer for 5 years or more after diagnosis.

Depending on the stage of the disease as well as the patient’s medical history someone can have

• Robotic radical prostatectomy with or without pelvic lymphadenectomy
• Radiotherapy
• Brachytherapy
• Focal therapy
• Chemotherapy
• Hormone therapy
• Immunotherapy
• Combinations of the above treatments 

This may seem like an odd question, but many localised prostate cancers grow too slowly to cause any problems or affect how long you live. Many men with localised prostate cancer will never need treatment.Furthermore prostate cancer is frequently diagnosed in elderly men or patients with very significant comorbidities in whom treatment usually carries more risks than the cancer itself.

If your test results show your cancer is unlikely to spread outside the prostate, you may decide to have your cancer monitored. This means you won’t have treatment unless the cancer starts to grow or you get symptoms. Instead, you will have regular check-ups, including PSA tests, MRIs and prostate biopsies, to check if your cancer might be growing.

In case the patient is not a candidate for treatment due to advanced age or comorbidities he also needs careful monitoring to detect any signs of disease progression ,in which case the management plan has to be discussed again with your Urologist.

Your treatment options will depend on whether your cancer is contained within the prostate gland, has spread just outside of the prostate or has spread to other parts of the body.

Your treatment options and which treatment you choose may depend on several things, including:

• how far your cancer has spread
• how quickly your cancer may be growing
• the advantages and disadvantages of each treatment
• what each treatment involves
• the possible side effects of each treatment
• your own thoughts about different treatments
• how the treatment you choose now could affect your treatment options later if your cancer comes back or spreads
• your general health
• how long you’re expected to live for.

• If the cancer is completely contained inside the prostate, surgery will remove all of the cancer.
• The prostate is looked at under a microscope to give a clearer picture of how aggressive your cancer is, whether it has spread outside your prostate and if you need further treatment.
• Your doctors can get a better idea of whether your cancer was completely removed during surgery. Your PSA level should drop so low that it’s not possible to detect it after surgery.
• If there are signs that your cancer has come back or wasn’t all removed, you may be able to have further treatment.
• Some men find it reassuring to know that their prostate has been physically removed.

• There are risks in having surgery, as with any major operation.
• You might get side effects such as erection problems and urinary problems.
• You may need to stay in the hospital.
• If the cancer has started to spread outside the prostate, the  operation may not be able to remove all of the cancer and you might need further treatment.
• You won’t be able to have children naturally or ejaculate after surgery as you won’t be able to produce semen, but it’s possible to store sperm before surgery for fertility treatment.

• If your cancer is localised or locally advanced, radiotherapy will aim to get rid of the cancer completely.
• Many men can carry on with many of their normal activities while having treatment, including going to work and driving.
• Radiotherapy can be an option even if you’re not fit or well enough for surgery.
• The treatment itself only lasts around 10 minutes,though you will need to do it daily for a month or so, depending on the protocol you follow.

• Your bladder may need to be full, and your bowel may need to be empty during each treatment session. You may be given medicine to help empty your bowel each day and it could take a while to work. Some men may find this process difficult and inconvenient.
• You may need to have concomitant hormonal therapy with all its side effects.
• Radiotherapy can cause side effects such as bowel, urinary and erection problems, as well as tiredness and fatigue. 
• There is an increase in the risk of getting other cancers after radiotherapy. 
• It may be some time before you know whether the treatment has worked.
• If you have radiotherapy as your first treatment and your cancer comes back or spreads, it might not be possible to have surgery afterwards and the operation itself will carry significantly more risks than if you had it in the first place. This is because the radiotherapy may have damaged the prostate and surrounding tissues, making it harder to remove the prostate.

Robotic prostatectomy is minimally invasive prostate removal surgery to treat prostate cancer. Surgeons remove the prostate using slim, specialised instruments and a camera.

The main advantages of robotic surgery over the older techniques are:

• Reduced post-surgery pain.
• Less blood loss.
• Fewer and smaller scars.
• Increased precision
• Faster recovery.
• Shorter hospital stay.
• Less risk of infection.

It is not surprising the fact that in most advanced health systems far more than 90% of prostate cancer surgery is done robotically and most surgeons have completely shifted from open and laparoscopic to robotic surgery.

No, this surgery involves operating in a very narrow space and dealing with very delicate structures like the nerves responsible for erection, the sphincters and the rectum. Also it requires very deep knowledge of the anatomy and physiological anatomic variations of the area as well as understanding of the functional significance of each anatomic element.

Furthermore it is the most typical example of an operation that details determine the outcome.
For those reasons you should only trust Urologists that have completed a formal training program in a high volume centre.

Retzius sparing prostatectomy, often referred as a newer technique is not exactly very new as its conception dates back to 2011 and it was offered in many centres since 2014.It has promising results for urine continence after the operation but with a few disadvantages.

In any case your Urologist will discuss all the available options and based on your unique characteristics ,will guide you to the best decision.To our experience all different approaches have almost the same outcomes if the operation is performed properly. 

Patients usually stay in the hospital for 1 night but if the patient wishes so and his operation is early in the morning he can even go home on the same day.

There is no single answer to that,as it depends on the initial stage and the stage of the recurrence of the disease and the treatment given initially.  In general patients who have localised recurrence in the pelvic area and their initial stage was also localised can be managed with radiotherapy if they had surgery in the first place and the other way around if they had radiotherapy initially they can have surgery.

The reality is that treatment of recurrent prostate cancer is a complex decision and it should be discussed thoroughly with your Urologist and Oncologist.

The operation to remove the prostate and possibly the lymph nodes after previous treatments like radiotherapy,brachytherapy, focal therapy etc is also called salvage prostatectomy. It is a very,technically,demanding procedure that carries significantly more risks due to poor healing and fibrosis secondary to previous treatments.

This understandably means that it is performed only from a few Urologists who have proper training and the experience to deal with the challenges of those procedures and achieve good oncological and functional results.